NAME: ______Date______

WEIGHT HISTORY

What has been your heaviest weight? _____lbs. What is the least you have ever weighed as an adult? ______lbs.

1.Your present weight: ______Height: ______

2.Describe your present weight (check one) Obese ____ Very Overweight____ Slightly Overweight ____

3.How long have you been overweight? a. Less than one year b. 1-5 years c. Five or more years

4.When did your weight problem begin?

a. As a child b. As a teenager c. Adulthood/After Marriage d. After Childbirth e: Other __

5.Which other family members are obese?

a. Motherb. Fatherc. Siblingsd. Childrene. Spouse

6.Do you feel you can lose weight easily through your own efforts? Yes / No

7.Appetite suppressant medications are optional in our programs. Do you prefer to use suppressants? Yes /No

8.Present or past history of eating disorders? Yes / No

9.Anorexia- fear of weight gain leading to malnutrition and usually excessive weight loss ___ Yes

10.Bulimia- overeating followed by vomiting, laxative/diuretic abuse and/or excessive exercise ___ Yes

11.Binge Eating Disorder- consuming a large quantity of food in a short period of time ___ Yes

12.Night Eating Disorder- eating very late at night, waking up in the middle of the night to eat. ___ Yes

DIETARY HISTORY

Approximate age you first seriously started dieting: ______

Please identify the diets and diet programs you have tried, if any:
Program / YES / NO / Date / Duration / Program / YES / NO / Date / Duration
Jenny Craig / Atkins Diet
Weight Watchers / Metabolife
Nutri-Systems / MediFast
Behavior Modification / Intestinal Bypass
Supervised Diet / Hypnosis
Your own diet / Stomach Stapling
Starvation/Liquid Diet / Gastric Bypass
HCG Shots / Other:
Appetite Suppressants / Other:
OptiFast / Other:

Eating Habits: ___ Sweets ___ Salty snacks ___ Portion Control ___ Skipping meals

NAME: ______Date______

SOCIAL HISTORY

Marital Status: __Single __Engaged __ Married ___Partner ___Separated ___Divorced __Widowed/Widower

Do you use tobacco? ___ Never Smoked ___ Current Smoker

Do you use alcohol? ___Yes __No If yes, how often: ______Type of alcohol: ______

Do you currently use recreational drugs? ___Yes ___No

If no, have you ever used recreational drugs? ___Yes ___No

Have you ever been treated for narcotic/ alcohol dependency? ___Yes ___No

MEDICAL HISTORY

Medical Condition / Current / Past / Medical Condition / Current / Past
AIDS / Hemorrhoids
Alcohol Abuse / Hepatitis A
Allergies (Seasonal) / Hepatitis B
Angina / Hepatitis C
Anxiety / Hernia
Arthritis / High Blood Pressure
Asthma / High Cholesterol
Back Pain / High Triglycerides
Bleeding Abnormality / Incontinence
Blood Clot / Infertility
Bronchitis / Irregular Menses
Cancer / Irritable Bowel
Colitis / Kidney Disease
Crohn’s Disease / Kidney Stones
Deep Vein Thrombosis / Liver Disease
Depression / Lung Disease
Diabetes I / II / Mental Illness
Diverticulitis / MI/ Heart Attack
Emphysema / Neuropathy
Endometriosis / Planter Fasciitis
Epilepsy / Polycystic Ovarian Syndrome
Fatty Liver / Pulmonary Embolus
Gallbladder Disease / Rheumatic Fever
Gestational Diabetes / Shortness of Breath
Gout / Sleep Apnea
Heart Disease / Stomach Ulcer
Heart Palpitations / Stroke
Heart Murmur / Thyroid Problems
Other: / Other:

NAME: ______Date______

SURGICAL HISTORY

Type of Surgery / Date of Surgery

FAMILY HISTORY

Additional Family History: (check the ones that apply)

Disease /Problem / Mother / Father / Sibling
Alcoholism
Cancer
Diabetes
Heart Disease
Hypertension
Sleep Apnea
Stroke
Other:
Other:
Other:

MEDICATION ALLERGIES

□ Check here if you have no known drug allergies

Medication / Type of reaction

Are you allergic to Latex? ___Yes ___No

Are you allergic to Iodine? ___Yes ___No

Are you allergic to surgical tape? ___Yes ___No

NAME: ______Date______

MEDICATIONS- PRESCRIPTION, HERBAL, OVER THE COUNTER

How many times per week do you take Ibuprofen or Aspirin? ______

Medication Name / Dosage

Name: ______Date: ______

Please fill out the following questions with honest answers:

What is your typical breakfast? ______

What is your typical lunch? ______

What is your typical dinner? ______

What is your “go to” snack? ______

Do you drink soda, diet soda, or energy drinks? ______If yes, how many per day? ______

How many hours of sleep do you average per night? ______

Are you tired during the day? ______

Do you have an exercise routine? ______

Do you cook? ______

Do you drink alcohol? ______If so, how much per day? ______

How many meals do you eat out per week? ______

Do you “crash” 1-2 hours after eating? ______

Do you find yourself “starving” mid/late morning or mid/late afternoon? ______

Have you been diagnosed with auto immune disorder/disease? ______If yes, which disorder/disease? ______

Do you have food allergies/sensitivities? ______If so, what foods?______

______

When did you start gaining weight that became difficult to lose? ______

How likely are you to count calories or net carbohydrates every day? (Please circle below)

Never Not likely Maybe Likely Always

Version: 11/2017